不同方法输注机余血对瓣膜置...术患者围术期凝血功能的影响_刘玉妍.pdf

论著 临床论坛CHINESE COMMUNITY DOCTORS中国社区医师2023年第39卷第2期不同方法输注机余血对瓣膜置换术患者围术期凝血功能的影响刘玉妍刘小丹谢伟贤梁秀生龚建平511518广州医科大学附属第六医院(清远市人民医院)麻醉科，广东 清远doi:10.3969/j.issn.1007-614x.2023.02.018摘要目的：探讨不同方法输注机余血对瓣膜置换术患者围术期凝血功能的影响。方法：选取2018年1月-2021年12月广州医科大学附属第六医院收治的40例瓣膜置换手术患者为研究对象，根据随机数字表法分为试验组与对照组，各20例。试验组在拔出主动脉插管前，全部机余血从主动脉直接回输给患者；对照组在拔出主动脉插管后，全部机余血回收到储血袋，在3 h内从颈内静脉全部回输给患者。比较两组凝血功能指标、血常规、患者鱼精蛋白追加量、关胸止血时间、胸腔引流量。结果：试验组术后即刻活化部分凝血活酶时间(APTT)、凝血酶时间(TT)短于对照组，差异有统计学意义(P0.05)；试验组术后第1天APTT短于对照组，差异有统计学意义(P0.05)。两组术前红细胞压积、血红蛋白比较，差异无统计学意义(P0.05)；试验组术后胸腔引流量、术中鱼精蛋白追加量少于对照组，关胸止血时间短于对照组，差异有统计学意义(P0.05)。结论：机余血经主动脉插管从主动脉直接回输的方法较机余血回收到储血袋，再从颈内静脉回输的方法能明显改善术后凝血功能，减少术中鱼精蛋白使用量、缩短关胸止血时间，减少术后胸腔引流量，可有效预防术后因肝素过剩导致的出血渗液。关键词瓣膜置换手术；凝血功能；机余血；鱼精蛋白Effects of Different Transfusion Methods of Machine Residual Blood on Perioperative Coagulation Function ofPatients Undergoing Valve ReplacementLiu Yu-yan,Liu Xiao-dan,Xie Wei-xian,Liang Xiu-sheng,Gong Jian-pingDepartment of Anesthesiology,The Sixth Affiliated Hospital of Guangzhou Medical University(Qingyuan Peoples Hospital),Qingyuan 511518,Guangdong Province,ChinaAbstractObjective:To investigate the effects of different transfusion methods of machine residual blood on perioperativecoagulation function of patients undergoing valve replacement.Methods:A total of 40 patients undergoing valve replacementsurgery in the Sixth Affiliated Hospital of Guangzhou Medical University from January 2018 to December 2021 were selected asthe study subjects.According to random number table method,the patients were divided into experimental group and controlgroup,with 20 cases in each group.In experimental group,before pulling out the aortic cannula,all the residual blood was directlyreinfused via the aorta to the patients;In control group,after pulling out the aortic cannula,all the residual blood was recovered tothe blood storage bag and reinfused to the patient via the internal jugular vein within 3 h.Blood coagulation function indexes,bloodroutine test,additional amount of protamine in patients,time of hemostasis in thoracic closure,and thoracic drainage amount in thetwo groups were compared.Results:The activated partial thromboplastin time(APTT)and prothrombin time(TT)in theexperimental group were shorter than those in the control group immediately after surgery,and the difference was statisticallysignificant(P0.05).The APTT in the experimental group was shorter than that in the control group on postoperative day 1,and thedifference was statistically significant(P0.05).The postoperative thoracic drainage amount and intraoperative protamine addition amount in theexperimental group were less than those in the control group,and the time of hemostasis in thoracic closure was shorter than that inthe control group,and the difference was statistically significant(P0.05).Conclusion:Compared with the method of recoveringmachine residual blood in blood storage bag and then reinfusing to the patient via the internal jugular vein,the method of directreinfusion of machine residual blood from the aorta through aortic cannulation can significantly improve postoperative bloodcoagulation function,reduce the amount of protamine used during the operation,shorten the time of hemostasis in thoracic closure,reduce postoperative thoracic drainage,and effectively prevent postoperative bleeding and exudation caused by excessive heparin.Key wordsValve replacement surgery;Coagulation function;Machine residual blood;Protamine基金项目清远市科技计划项目(编号：180614161900442)体外循环(CPB)辅助下心血管外科手术异体血输注量非常大，占所有外科手术用血量的首位，导致医疗用血供需不平衡。为有效解决医疗用血供需矛盾，体外循环机余血回输是相对安全、经济的方式。传统的输注方法是将未经处理的机余血回收入贮血袋，直接从静脉回输给患者，回输过程往往会出现创面渗血54论著 临床论坛CHINESE COMMUNITY DOCTORS中国社区医师2023年第39卷第2期表1两组术前凝血功能比较(xs)组别nPT(s)APTT(s)INRTT(s)Fbg(g/L)对照组2012.291.6726.562.781.040.1317.074.463.021.15试验组2013.964.9328.724.971.200.4417.862.203.161.05t1.4351.6961.5600.7100.402P0.1600.0980.1270.4820.690表2两组术后凝血功能比较(xs)组别nPT(s)APTT(s)术后即刻术后第1天术后即刻术后第1天对照组2014.701.6813.872.2042.7524.5237.1521.64试验组2014.721.5313.962.1531.025.8026.933.24t0.0390.1312.0822.089P0.9670.8970.050.05组别nINRTT(s)Fbg(g/L)术后即刻术后第1天术后即刻术后第1天术后即刻术后第1天对照组201.190.311.110.3330.0523.0725.1529.972.511.624.322.26试验组201.170.311.080.3118.006.9116.471.032.410.753.91.41t0.2040.2962.2381.2950.2510.705P0.8390.7690.050.2030.8040.485增加，关胸、止血困难，导致手术时间延长。本次研究旨在探讨不同方法输注机余血对瓣膜置换术患者围术期凝血功能的影响，现报告如下。资料与方法选取2018年1月-2021年12月广州医科大学附属第六医院收治的40例瓣膜置换手术患者为研究对象，根据随机数字表法分为试验组与对照组，各 20例。试验组男 8 例，女 12 例；年龄 3578 岁，平均(48.577.53)岁；体重4286 kg，平均(57.9410.11)kg；美国麻醉师协会(ASA)分级：级 9例，级 11例。对照组男 12 例，女 8 例；年龄 3977 岁，平均(47.909.86)岁；体重4384 kg，平均(55.9012.82)kg；ASA分级：级7例，级13例。两组患者基本资料比较，差异无统计学意义(P0.05)，具有可比性。本研究经院医学伦理委员会审核批准。纳入标准：患者ASA分级级；患者心功能分级级；患者年龄2060岁。排除标准：再次行心脏瓣膜置换术的患者；术前需输注同种异体血的患者；近6个月内有心肌梗死或近3个月内有心功能衰竭的患者；凝血功能异常的患者；严重高血压的患者；肝、肾功能不全的患者。方法：两组均采用Stockerts型人工心肺机进行体外循环，试验组在心脏复跳后，静脉泵注小剂量硝酸甘油，停体外循环至鱼精蛋白中和前，把膜式氧和器贮血罐中的机余血由主动脉插管直接回输患者体内，再往贮血罐中加入400 mL肝素水(500 mL乳酸林格氏液加入10 mg肝素后取400 mL)，在鱼精蛋白开始中和至拔出主动脉插管前，用肝素水把管道内所有机余血置换出来，从主动脉插管直接回输至患者体内。对照组采用传统方法，在拔出主动脉插管后，把贮血罐全部机余血回收到储血袋，再往贮血罐中加入400 mL肝素水，把管道内置换出来的全部机余血